Provider Demographics
NPI:1194966879
Name:GOODRICH, NICOLE H (MS, RD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:H
Last Name:GOODRICH
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:H
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:4904 S. POWER RD
Mailing Address - Street 2:#103-188
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212
Mailing Address - Country:US
Mailing Address - Phone:602-770-7611
Mailing Address - Fax:480-505-3077
Practice Address - Street 1:20801 N SCOTTSDALE RD
Practice Address - Street 2:#205
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255
Practice Address - Country:US
Practice Address - Phone:602-770-7611
Practice Address - Fax:480-505-3077
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-10
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered